The clinic has a reputation for aggressively pushing euthanasia. Of the 162 patients it euthanized in 2012, the year of study, 8.2% were suffering from a psychological or psychiatric ailment and 7% were "tired of life." It has a growing fleet of mobile vans (about 40 at the moment) which buzz around the countryside assessing patient's requests for euthanasia. Nevertheless, it "granted fewer requests for euthanasia and physician-assisted suicide than are granted in the Netherlands on the whole."

So the report - which was funded by the end-of-life clinic - paints a picture of moderation and sound judgment on the part of euthanasia doctors.

First, they argue that "values of autonomy and self-determination" have become more important for the Flemish. And approval of euthanasia continues to rise, perhaps with the help of very positive reporting in the media.

The second reason is that doctors are more willing to perform euthanasia. Like their fellow citizens, they esteem autonomy, but they also are confident that they will not be prosecuted. Euthanasia is treated "as part of the palliative care continuum, as formally expressed in a position statement from the Federation of Palliative Care Flanders."

American observers were alarmed by this new data. "As the number of overall deaths like this becomes more frequent than 1 in 20, say, I think red flags really need to be raised," the author of a commentary in the same issue, Dr. Barron Lerner told Reuters

"Most of us were trained to never condone speeding death at all," he added.

"To the degree that some physicians are comfortable doing so, they will be in cases in which someone has an intractable physical suffering that will only persist or get worse; it is quite a leap for most of us to also see psychological suffering as a valid reason for speeding death."

Dr. Lerner and bioethicist Arthur Caplan wrote a commentary for JAMA Internal medicine titled "Euthanasia in Belgium and the NetherlandsOn a Slippery Slope?" .